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  #1  
Old 05-07-2010
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ObGyn Pregnant woman suffered a car accident

A 19-year-old woman at 32 weeks’ gestation is the driver in a front-end motor vehicle crash. The air bags did not inflate, and the patient sustained blunt trauma to the abdomen. The patient is taken to a nearby ED in stable condition, where she notes a small amount of bright red blood on her underwear. Maternal vital signs are significant for a heart rate of 110/min
and a blood pressure of 110/55 mm Hg. What is next most appropriate step in management?
(A) Administration of Rho(D) immune globulin
(B) Disseminated intravascular coagulation panel
(C) External fetal heart rate and uterine monitoring
(D) Immediate cesarean delivery
(E) Immediate vaginal delivery
(F) Internal fetal heart rate and uterine monitoring
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Old 05-07-2010
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This is a case of late-pregnancy vaginal bleeding and should be addressed as so. We should not jump to conclusions such as pregnancy + car accident = abruptio placenta, mainly because there is no pain described in the question stem.

1) During primary assessment, the mother seems to be hemodynamically stable, and generally her ABCs seem fine. This may be deceiving, because pregnancy is a hyperdynamic condition and it may take time for shock to manifest clinically as hypotension, thus our suspicion threshold should be low and fluid resuscitation should be aggressive in pregnant trauma patients. A hint for this may be the tachycardia of this mother. However, there is no such option available among the answers. The point is that, as soon as the mother is hemodynamically stable now and the amount of bleeding is not massive, there is no point in proceeding to emergency cesarean delivery.

2) The fetus should be assessed next. There is no rationale for rushing to the delivery or the operating room, as long as there is no evidence of the fetus' well (or not-well) being. Vaginal delivery would be indicated if pregnancy was beyond 36 weeks or if there was evidence that the fetus is dead; none of these are true here. So, I would proceed to fetal monitoring. The findings of cardiotocography will mandate our next steps in management.

3) Between external and internal cardiotocography, I would prefer external, because we don't know whether the membranes have ruptured or not, where does the placenta or the umbilical vessels lie (an ultrasound should be preceded) etc, in order to use internal monitoring. No vaginal manipulations should be made until we assess the status of the pelvic contents. So, I would go for choice C.

4) After the initial assessment of mother and fetus, I would run a series of tests (CBC, blood type and cross-matching, DIC workup). RhoGAM should be administered only if the mother is Rh(-) and within 72 hours post-partum.


Your feedback is valuable, because I am not sure if my rationale is correct (I mean, I haven't taken my ALSO courses yet!)...
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Old 05-12-2010
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On the other hand, I return to doubt my own reasoning and state that this may be considered a case of placental abruption, for the purposes of the USMLE.

I explain myself: abruptio placentae may infer major damage to the embryo but none to the mother; besides, hemorrhage due to abruptio placentae may be minimal, due to accumulation of blood in the space between the placenta and the decidua.

So, perhaps the USMLE wants us to postulate that is a de facto case of abruptio placenta. However, I still think that fetal monitoring should be our first priority, before rushing to the OR.

Waiting impatiently for your feedback, Dr. RRMadukha!
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Old 05-12-2010
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Correct Answer The correct answer is C

Abruptio placentae refers to premature separation of a normally implanted placenta after 20 weeks of gestation, but prior to delivery of the infant. Since the detached portion of the placenta is unable to exchange gases and nutrients, the fetus can become compromised if the area of separation is large. This patient is at risk for placental abruption secondary to compression decompression and acceleration-deceleration stresses of a motor vehicle crash. Vaginal bleeding in this setting is concerning, as bleeding is one of the first signs of abruption. It is unlikely that a complete abruption has occurred, as the patient is not frankly hypotensive and her bleeding was minimal. All women > 24 weeks of gestation subjected to abdominal trauma should have continuous fetal and uterine monitoring with an external fetal heart rate to assess for preterm labor and/or an abruption. Signs of fetal compromise are associated with moderate to severe abruption and would necessitate immediate delivery.

Answer A is incorrect. Administration of Rho(D) immune globulin is appropriate in an unsensitized Rh-negative female. This patient’s blood type would need to be established prior to administration of this drug.

Answer B is incorrect. While patients with placental abruptions are at risk for developing disseminated intravascular coagulation (DIC), this patient does not exhibit signs of a coagulopathy. A DIC panel should be included in routine laboratory blood work on this patient; however, it is an inappropriate first step prior to the establishment of external fetal and uterine monitoring.

Answer D is incorrect. Although cesarean section is the appropriate method of delivery in a patient with a placental abruption, delivery is only warranted when there are signs of fetal or maternal compromise. This patient is at risk for fetal distress due to uteroplacental insufficiency, although further evaluation of the fetus is necessary prior to delivery.

Answer E is incorrect. Vaginal delivery is an inappropriate treatment for a patient with a placental abruption. Patients with abruptions who demonstrate signs of maternal or fetal distress and thus require emergent delivery should be delivered by cesarean section.

Answer F is incorrect. Internal monitoring requires the rupture of membranes, which would be inappropriate management of this patient prior to delivery.
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